to main content Case Study Ascensions Experience Switching to Joint Commission Accreditation | The Joint Commission

For most lab directors and managers, the prospect of having to undergo an accreditation process can feel like a hassle at best and a nightmare at worst. It can be a frustrating, time-consuming process — and one that isn’t remotely enlightening in helping the organization improve its quality.

Yet accreditation is crucial for holding medical labs to the highest possible standard and ensuring great patient care. So what if it were possible for the process to actually drive value and to have a positive impact on engagement and alignment?

That’s exactly what Laboratory Director Lynnette Chakkaphak experienced when her health system Ascension — a network of over 160 hospitals across the United States — decided to switch from its previous accreditation agency to The Joint Commission. Although Lynnette had worked in labs for over 45 years, this was her first encounter with this particular accreditation process.

“When something’s brand-new to me, I’m a little uncertain about it,” she admits. But despite her initial trepidation, by the end of the process, she says she was “so glad [they] made the change.”

She discusses why and how Ascension decided to switch accreditation agencies, all the resources and support her team received while preparing for the process and the experience of going through the survey for the first time. She also highlights the synergies that have been made possible by using a single accreditor across a large system — as well as the tangible impacts it has made within the organization and for those it serves.


Why and How Ascension Switched to Joint Commission

With so many hospitals spread across the country, Ascension had been relying on a patchwork of agencies for its accreditation needs. Some of their facilities were already Joint Commission-accredited, and others — like Lynnette’s four hospitals in Jacksonville, Florida — were using different providers.

The lab directors met as a group and began to consider uniting everything under a single agency. They created a task force to explore the pros and cons, and Lynnette became a member of that team. The task force members started this process by thinking about all the problems they had individually experienced during previous accreditations.

For example, Lynnette describes a situation where an inspector was insistent on finding a certain number of deficiencies — and kept everyone waiting in an attempt to do so. After a great deal of time and effort, all the deficiencies that the inspector did find were eventually overturned. “It was not helpful to our organization in any way,” she says.

Another important factor in comparing accreditation agencies was the peer inspections that are part of most agencies’ processes. “If somebody comes and inspects us, we are required to reciprocate and go inspect elsewhere,” Lynnette explains. This was becoming a drain on Ascension’s time and resources by keeping valuable lab workers away from their main focus.

After considering all the options, and despite some general resistance to change, the group found The Joint Commission to be the clear winner. Lynnette was cautiously optimistic. “When we feel comfortable and confident that our laboratories are in good shape, we might be reluctant to try a new process that would cause a lot of unknown,” she explains.

As Ascension navigated the complexities of the accreditation process, The Joint Commission was there to support it at every step with resources designed to ensure the team was well-prepared.


To help Ascension cross those initial hurdles and facilitate the transition, The Joint Commission assigned a manager to guide the team through the process. This certainly made the beginning much easier, Lynnette says. “It was like they were holding our hand with a big smile on their face and were so knowledgeable and reassuring.”

Not only was the manager available to answer any questions that arose, but they also provided training on how to use the Joint Commission Connect website. According to Lynnette, it was “a perfect resource,” offering a one-stop shop where all stakeholders could participate and work together to drive the accreditation forward throughout the entire health system.

As the Ascension team got ready for their survey, they would meet regularly to review and discuss the many different areas involved. When questions came up, they could submit them through the website — and get answers quickly. “There was fast turnaround time, and they were so gracious and detailed in their responses,” Lynnette says. This went a long way toward helping the team feel comfortable with the new process.

As she prepared for the survey, Lynnette felt like she had a “whole new rulebook” — and a thick one at that. But as a lab director who “wants to get an A+ on her report card,” she set about systematically breaking down The Joint Commission’s Standards and Elements of Performance chapter by chapter.

Some of the sections were lab-specific, but others required partnering with nurses and other departments of the hospital — or even system-wide collaboration. Lynnette was pleasantly surprised to see how this opened up a lot of dialogue that hadn’t been occurring previously. “Not that we were siloed,” she says, “but I certainly look at our accreditation process as a way of connecting with all the rest of the healthcare providers within our organization.”

Another great resource that Lynnette found on the website was the Joint Commission Survey Activity Guide, which was particularly useful for a first-time accreditation. “It helped us know exactly how to prepare, what to provide, what documents to have ready, what the opening conference was going to be like and what the basic flow of the survey would be,” she explains.

The guide also highlights the particular standards that laboratories most commonly struggle with, which Lynnette used to drive a lot of her team’s discussion and preparation. “We figured if other labs had trouble with those, so would we.” The team also received helpful “heads-up” messages advising them of common things that could go wrong.

When it came time for the actual survey, Lynnette says, “we basically felt prepared,” the result of having all these resources before the accreditation even started. But that preparedness wouldn’t have been possible without what she thinks is one of the biggest advantages of switching to The Joint Commission: “It really became much more of a group effort.”

According to Lynnette, when she mentions The Joint Commission within her health system, everyone snaps to attention and is immediately on the same page. And that carries from the C-suite all the way to the nurses, physicians and providers.

“Everybody is willing to jump in and help because they all understand the importance of Joint Commission accreditation — to the healthcare that we provide, to the quality we provide [and] to the assurance that we're providing the very best care for our patients,” she explains.

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“It was like [our Joint Commission manager was] holding our hand with a big smile on their face, and they were so knowledgeable and reassuring. It certainly made that beginning part of the process much easier. They were always available to answer our questions. They trained us on and walked us through The Joint Commission Connect website, and we found it to be a perfect resource.”

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“When I say Joint Commission within my organization — within my health system and my four hospitals — literally everyone pays attention. Everybody’s on the same page with me. Everybody is willing to jump in and help because they all understand the importance of Joint Commission accreditation — to the healthcare that we provide, to the quality that we provide, to the assurance that we're providing the very best care for our patients.”

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“Our conversion to the Joint Commission accreditation helped us to unite our laboratory with the rest of the healthcare team and improved our communication and understanding across our health system. Clearly, through that greater collaboration, we are going to experience a greater quality of care for our patients, and greater patient safety and satisfaction. I am certain that as we look at the patient outcomes, they will improve as well.”

The Survey Itself

Because Ascension was a first-time Joint Commission accreditation, the date of their inspection was announced to the team beforehand. Typically, an organization enters a ready date into the application, and the survey will be scheduled within 60 days of that date, with at least 30 days of advance notice. The survey process takes between two and four days, depending on the size of the facility and the number of inspectors.
Test tubes in a line with lIquid.
A person in lab coat working with test tubes.

When the survey team arrived, Lynnette describes them as being “extremely experienced and well-trained, extremely fair and unbiased, and certainly punctual and well-organized.” The process had a “totally different feel” from previous accreditations — perhaps because the survey team members were pathologists and lab directors, so “they felt just like us,” she posits.

The surveyors knew that Ascension was new, so Lynnette recalls them taking a great deal of time to explain what their focus would be and to ensure everyone felt comfortable.

“Immediately out of the mouth of the lead surveyor was the idea that the focus of the experience ahead of us was going to be an educational one,” she says. During the process, the surveyors engaged with the team and stopped to teach them things. That was something Ascension had never experienced before.

Lynnette describes these teaching moments as “thinking out loud” rather than dictating right and wrong. “There are many ways to meet the standards, and we were meeting the standard. The key was, Are there other ways to approach these things?” This open dialogue led to a sharing of ideas that became immensely valuable to the Ascension team.

Synergies of Using One Agency

Overall, Lynnette says, “It was really a positive and encouraging environment throughout, so it was a wonderful survey experience for us.” She describes how the process had her team interacting with physicians and nurses and going right into the electronic medical record. This engaged the lab with the rest of the hospital much more than had been the case in the past.

New lines of communication opened up, and, in Lynnette’s opinion, the entire health system benefited from The Joint Commission process. Groups outside the lab gained a better understanding of it and were impressed with their interactions. In turn, lab associates gained job satisfaction and grew to be seen as more valuable members of the overall healthcare team.

The results of the Joint Commission accreditation — and all the collaboration it brought about — are far-reaching. “We clearly are going to experience a greater quality of care for our patients and greater patient safety and satisfaction,” Lynnette explains. She says that she’s certain there will be improvements in patient outcomes as well. And that, after all, is what the whole endeavor is all about.